Case presentation:
A 69-year-old male with a history CLL, ITP, and recurrent tinea corporis presented to the hospital with an ulcerating lesion at the site of a previously diagnosed tinea corporis infection of his right medial ankle.
One month prior to presentation, the patient was started on high-dose steroids for treatment of refractory ITP. After 2-3 weeks of experiencing a limited response to steroid treatment, he was started on rituximab and ultimately hospitalized for refractory ITP. During this hospitalization, the patient’s ITP was thought to be triggered by CLL prompting the initiation of ibrutinib for treatment. Following the initiation of ibrutinib, he was seen by dermatology for a new pruritic, painful skin lesion on his right medial ankle. This skin lesion was painful to the touch and noted to be a well-demarcated bright red plaque with scattered hemorrhagic, dusky, purple papules within the plaque. There was a collarette of scale overlying the edge of the lesion. A skin scraping with potassium hydroxide preparation demonstrated numerous branching hyphae. A biopsy of the lesion was deferred due to thrombocytopenia (11,000/cmm). He was started on topical terbinafine 1% cream twice daily for presumed superficial tinea corporis infection. He was discharged once his thrombocytopenia stabilized. Less than one week from discharge, the patient’s distal right lower extremity became progressively more edematous with new ulceration and serosanguinous drainage (Figure 1). He presented to the hospital again and admitted for a second time (Table 1). He was evaluated with a computed tomography scan of the right lower extremity which demonstrated diffuse subcutaneous edema with pooling of fluid along the superficial fascia. There were no signs of focal fluid collection or subcutaneous emphysema. Due to clinical concern for necrotizing fasciitis, the patient was urgently taken to the operating room by general surgery where he underwent four-compartment fasciotomy of the right lower extremity as well as excisional debridement of the involved area at the right ankle until healthy appearing and bleeding tissue was reached.
Intraoperatively, there was extensive necrosis involving the dermis, subcutaneous adipose tissue, and superficial fascial layers which were debrided. The underlying muscle layers, tendons, and deep fascia appeared alive and healthy. Tissue was sent for culture and pathology. At the fasciotomy sites in the leg, there was a positive finger sign between the adipose and the fascia as well as between the fascia and the muscle, without frankly necrotic tissue in this part of the leg. While the fascia and muscle appeared healthy, this clinical finding of easy separation between the two tissue planes was thought to be representative of early-stage infection in which necrosis of the epimysium occurred without progression to widespread tissue necrosis. Therefore, no further sharp debridement was performed. Pulse lavage irrigation and debridement with nine liters of normal saline was then performed at the surgical sites.
Operating room cultures grew Trichophyton rubrum , as well as methicillin-susceptible Staphylococcus aureu s andEnterococcus faecalis. Pathology exam demonstrated numerous branching, septated fungal hyphae within purulent inflammation in subcutaneous tissue, fascia, and also intravascularly within a thrombosed blood vessel (Figure 2). On post-operative day three, the patient developed elevated temperatures and was noted to have skin findings on his left lower extremity similar to the early stages of his right lower extremity infection. On post-operative day four, he underwent excisional debridement of his new left lower extremity lesion at bedside. Deep tissue specimens of his left lower extremity lesion grew Trichophyton rubrum and pathological exam demonstrated purulent inflammation with necrosis and branching septated fungal hyphae. On post-operative day six, his right lower extremity wounds showed stability (Figure 3).
Ultimately, this patient received daily wound care with multiple dressing changes which allowed for his surgical wounds to granulate and fill in appropriately. He was treated with a three-week course of antibacterials for methicillin susceptible Staphylococcus aureusand Enterococcus faecalis cultured from the right lower extremity, and oral terbinafine 250mg daily for 12 weeks for his invasive dermatophyte infection of both extremities. Given the extensive debridement, his right lower extremity wounds were covered with split thickness skin grafts six weeks post-operatively. At a clinic visit two weeks after completing terbinafine treatment, the patient had well healed skin grafts with no signs of recurrent infection.